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12.

0 OPHTHALMOLOGY
Last Revised: APR 15 Last Reviewed: APR 15

April 2015 updates include:


- NEW Chapters on Central Serous Retinopathy (12.18), Pigment Dispersion Syndrome
(12.19), Peripheral Retinal Degeneration and Retinal Hole (12.20), including guidance
on local board eligibility
- Updates to Refractive Surgery Chapter, including new surgical center for Class I
Aviators (Wilford Hall, San Antonio), expanded pre-op limits for designated personnel,
information on recommended wait times after surgery
Contact information: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil
Contact Phone: 850-452-2933

12.1 CATARACT
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Cataracts reduce visual acuity (VA). When the cataract involves
the visual axis, visual acuity is most affected in bright sunlight and conditions of glare.

WAIVER: The condition is considered disqualifying. Once vision has deteriorated to less than
20/20 correctable or the patient has a positive Glare test, the flier should be disqualified from
flying until successful surgical removal of the cataract. Waiver to SG1 may be considered after
surgery provided the VA returns to 20/20 corrected, is within refraction limits, and the Glare test
is negative (normal).

INFORMATION REQUIRED:
1. Ophthalmology consultation is required for initial waiver request.
2. Because of the potential for deterioration, ophthalmologic follow-up may be needed
every 6 months until surgery is deemed necessary.
3. Prior to and after surgery, a Mentor Brightness Acuity Test (BAT, a glare-testing device)
should be performed with VA documented for each eye separately at the low, medium
and high settings.
4. Confirmation is needed of exclusion of underlying pathology such as Wilson's disease,
diabetes or hypoparathyroidism.

TREATMENT: Surgery with an intraocular lens (IOL) implant usually provides a sufficiently
acceptable VA result for military flying duties. Consultation with NAMI ophthalmology prior to
surgery is recommended.

DISCUSSION: The visual effect of a cataract depends on its encroachment on the visual axis
and the proximity to the nodal point. A posterior subcapsular cataract can have a devastating
effect on vision. 2 to 3 episodes of serious dehydration can increase the risk of developing a
cataract 21 fold. Surgical success of greater than 90% in achieving a 20/40 best corrected VA
after 1 year has been reported. The RAF restricts the flying of personnel with IOL from high
performance aircraft and helicopters. This is because of the risk of pressure on ciliary body
blood vessels under high Gz or vibration and because of the unknown long term effect on the
corneal epithelium.

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ICD-9 CODES:
366 Cataract
366.1 Posterior Sub-Capsular Cataract (senile)
366.20 Traumatic Cataract
366.45 Drug induced Cataract
743.30 Congenital Cataract

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12.2 COLOR VISION ABNORMALITIES
Last Revised: JUN 15 Last Reviewed: JUN 15

AEROMEDICAL CONCERNS: Color vision is required to accurately identify warning lights and
color visual displays in the cockpit, airfield and shipboard lighting, colored smoke in combat,
ground target identification, and aircraft formation lights. Interactions with other optical devices,
such as laser eye protection glasses and protective visors may worsen color vision problems.
For testing purposes, proper instructions and lighting are critical to accurate results. Best
corrected spectacles are recommended, but no tinted or colored lenses may be worn during
testing, as that will decrease the sensitivity of the test for detecting color vision deficiency.

WAIVER: Applicants are CD, no waiver if the applicant cannot pass the required color vision
tests. Certain non-aviators require adequate color vision, including ATC, UAV, and sonar
display operators (anti-sub aircraft). Waivers have been granted for aeromedical and other
Class II aircrew applicants on a case-by-case basis. Waivers for designated personnel with a
change in color vision may be considered on a case-by-case basis.

COLOR TESTS:
1. Pseudo-Isochromatic Plates (PIP) are considered a primary test of color vision.
Approved: Ishihara 38-plate edition, Pseudoisochromatic Ishihara Compatible
(PIPIC) 24-plate edition, ColorDx Standard 24-Plate Edition.
a. Scoring: 12 (or more) of 14 correctly identified red/green numerical test plates
constitute a passing score. Passing criteria is 12 or more plates correctly read, i.e.,
no more than 2 errors.
b. Use one demonstration and 14 test plates (the orange number on page one is a
demo plate only, and not a test plate, and should not be counted). Directions: Best
corrected vision, Daylight Illuminator stand or a light source ~ 6500 degree Kelvin
temperature “Daylight” fluorescent bulb, three seconds each page, no tracing
allowed, random order. Regular white incandescent bulbs may not be used, as they
are the incorrect color and reduce the sensitivity of the test.
c. Other editions of pseudoisochromatic plates may not have the correct types of plates
(numbers only required). Research has shown that individuals scoring 11 (or less)
on the PIP test do not have normal color vision.

2. Farnsworth Lantern (FALANT), The Farnsworth Lantern was designed in the 1940’s to
pass mildly color vision deficient individuals for Naval submarine service. Passing the
FALANT does not ensure normal color vision. Original model or modern Optec 900
accepted. Certain aviation classes may not use FALANT (per MANMED).
a. Passing criteria for FALANT remains 9 of 9, or 16 of 18 correct responses.
Directions: normal room lighting, best corrected vision worn, both eyes open, 8 foot
test distance, random presentation of targets, two seconds each target. Prior to
testing, read the instructions to the patient exactly as written on the side of the unit to
ensure predictable responses, and follow all directions on the guide.
b. The FALANT will be phased out eventually from all classes, but those designated
and student aviators who have passed the FALANT prior to phase-out will be grand-
fathered for their career, unless a documented color vision degradation requires
further evaluation to exclude progressive or acquired disease.

3. Computerized Color Vision Tests (CCVT) may be either used as a primary test of
color vision, or may be used as a backup test for PIP or FALANT failures.

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Computerized Tests (validated and approved):
a. ColorDX (Waggoner): A score of “normal” or “mild” color vision deficiency in red,
green or blue is acceptable for aviation. Tested binocularly (both eyes open). May
test monocularly for isolating and tracking acquired color vision defects.
b. Colour Assessment & Diagnosis (CAD, City University London): A score of less
than or equal to 6 CAD units for all three cone types in each eye. Tested binocularly
(both eyes at the same time).
c. Cone Contrast Test (CCT, Rabin): A score of 55 or greater in each eye is required
for all three cone types. This test is given monocularly (one eye at a time).
d. Computer tests shall be administered per manufacturer recommendations with
regard to distance, lighting, screen calibration, and monocular or binocular testing.
Best correction worn. Computerized tests must be utilized per manufacturer’s
instructions; such as administration processes and calibration, room lighting, and
screen brightness. Computer-printout grade sheets should be submitted with the
physical exam, to ensure objectivity and correctness.

INFORMATION REQUIRED: If a designated crewmember fails the PIP, and either a FALANT
or computerized test (worse than mild defect), an ophthalmologic evaluation is required to
screen for acquired pathology. Additionally, a practical test of color vision must be performed,
and administered with the objective oversight of the flight surgeon, type standardization
instructor, and type NATOPS officer as observers. Tests would include identification of cockpit
lighting, gauges, safety indicators, cockpit display symbology, map symbology for both cockpit
and actual charts (hazards/obstacles, airspace coordination areas, route markings, etc.),
identification of shipboard and landing field lighting, and ALDIS lights. For Marines, smoke color
identification testing is also required. A control group of two additional aviators with normal
color vision is recommended for comparison. Commanding Officer endorsement is required.

TREATMENT: N/A.

DISCUSSION: Defective color vision is overwhelmingly congenital, and mainly involves red and
green cones, due to X-linked genetics. Blue cones are encoded on Chromosome 7. In
Caucasians, approximately 8% of males have inherited red/green color defective vision. Of
males, 2% of the population have only two cones, “dichromats”, and are severely deficient.
The majority of color deficient individuals have three cone types, “trichromats”, but are red or
green weak. Moderate to severe color deficient individuals have increased difficulty interpreting
VASI and PAPI lights' correctly, as well as difficulty with navigation and shipboard lighting and
colored smoke identification. Color deficient individuals also take a longer time to interpret color
signals and targets, while also making more errors, than individuals with normal color vision.

Blue color deficiency may be acquired by ocular diseases, including cataracts, optic neuritis,
macular degeneration, central serous retinopathy, or side effects of medications or toxins.

Mild color vision deficiencies are considered acceptable for safe flight. Moderate-to-severe red-
green abnormalities are the most problematic for aviation, and those individuals can sometimes
pass the FALANT. Any degree of color vision deficiency, even mild, should always be
considered as a potential causal or contributing factor in mishap investigations.

ICD-9 CODES:
368.5 Color Vision Abnormalities

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12.3 DECREASED VISUAL ACUITY
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Decreased visual acuity degrades lookout and target


acquisition.

WAIVER: A waiver for visual acuity less than standards may be considered in designated
individuals, provided the central and peripheral retina is normal and all other visual standards
are met.

Category Unaided Visual Acuity Refractive Limits NATOPS Restrictions

SG1 20/100 or better each eye None None

SG2 20/200 or better each eye None * Restricted from shipboard


duties including VSTOL
* Helicopters OK

SG3 20/400 or better each eye None * Dual Controlled only


* Requires SG1 or 2 onboard
* Pilot in Command is included

Consider whether a waiver is actually required. An aviator whose vision is worse than 20/400
will need a waiver to fly in any Service Group. A clear justification is required, including primary
type of aircraft in which he or she will be flying and the number of hours in that type of aircraft.

INFORMATION REQUIRED:
1. Optometry or ophthalmology consults for any waiver request for excessive refractive
error.
2. Ophthalmology consult required for cases of decreased visual acuity not due to simple
myopia, hyperopia, astigmatism or presbyopia (i.e. amblyopia, optic neuritis, corneal
scarring, cataracts, etc.)
3. Obtain dilated retinal evaluation at corrections greater than -8.00 diopters.
4. Progressive astigmatism should be evaluated to exclude keratoconus.

TREATMENT: Refraction by spectacles within the limits set by MANMED Chapter 15. Contact
lenses are permissible for aviation personnel after optometry examination, but spare clear
spectacles must be carried in flight and the aviator must demonstrate 20/20 with contact usage.
Other corneal surgical procedures (not allowed by Chapter 12.15) are CD, no waiver.

DISCUSSION: Myopia is usually a progressive condition, stabilizing around age 30. Significant
myopia is complicated by considerable visual distortion at the periphery of corrective lenses.
Individuals with significant myopia may see halos or flares around bright lights at night and are
more at risk for night blindness. Elongated globes are at an increased risk of retinal detachment
and lattice degeneration. Whenever a prescription is changed, aircrew should be warned about
transient visual distortion and counseled on the period of adjustment. Evidence suggests that
there is no difference in civil accident rates or in Naval carrier landing accidents in pilots who
require visual correction. Severe myopia tends to be a problem pertaining to Class II personnel
since the entry requirements for other pilots tend to be sufficiently stringent to exclude those
whose vision would deteriorate that much. The risk of retinal detachment in normals is 0.06%

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over 60 years compared to 2% in 5 diopter myopes. Beyond -9.75 diopters, the risk increases
to 24%. Recent studies of radial keratotomy suggest that the procedure leaves 28% of the eyes
with unstable refraction and nearly all with glare problems.

ICD-9 CODES:
367.9 Decreased Visual Acuity
367.9 Ametropia [Includes Myopia and Hyperopia]
367.95 Ametropia, exceeding standards
368.0 Amblyopia

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12.4 DEFECTIVE DEPTH PERCEPTION
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Although many visual cues regarding the relative positions of
objects in space (depth perception) are monocular. The binocular visual reflex of stereopsis is
an important indicator of normal visual acuity in each eye, with normal ocular alignment and
neurological function. Defective stereopsis may make certain piloting duties such as formation
flying and aerial refueling more difficult and unsafe.

WAIVER: No waivers shall be recommended for any candidate or designated Class I duty
involving actual control of aircraft. Class II and III personnel must meet standards for depth
perception except when remarked as "not required" under types of aviation duty specified under
MANMED Articles 15-87 through 15-99.

INFORMATION REQUIRED:
1. Valid tests of stereopsis include:
a. Armed Forces Vision Tester (AFVT)
b. Stereoacuity Plates used with polarized viewers such as the Stereo Optical, Titmus
Optical Stereo Fly, or Randot. A randomized version of these tests should be used.
c. Verhoeff Stereopter: tested at 1m, eight correct of eight random presentations for
passing grade.
2. A pass of any one test meets the stereopsis standard. The tests must be administered
and results recorded as specified in MANMED and elsewhere in the ARWG.
3. Recent loss of stereopsis in a designated Class I naval aviator is usually due to a
change in refraction or onset of presbyopia, but may also be a sign of cataract, macular
or optic nerve disease, or new motility disturbance, requiring ophthalmologic or
optometric evaluation. New failures to meet the stereopsis standard must be evaluated
by an ophthalmologist including completion of the ocular motility worksheet (See chapter
12.14).

TREATMENT: Correct any underlying refractive error or eye disease.

DISCUSSION: Defective stereopsis is typically innate and due to abnormal visual development
prior to the age of 9. The Verhoeff Stereopter tests stereovision in real space. Eight test
presentations are made at a 1 meter distance, with no head movement of the patient. All eight
tests must be correct for a passing score. Causes of defective stereopsis include abnormal
ocular muscle balance, amblyopia, anisometropia, microtropia, and monofixation syndrome.

ICD-9 CODES:
368.33 Defective Depth Perception

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12.5 HISTORY OF STRABISMUS SURGERY
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Single, fused, simultaneous binocular vision in all versions at all
times with the stereopsis reflex active is a requirement for safe and effective duty involving
actual control of aircraft. Congenital or acquired defects of ocular alignment as well as any
surgery to correct ocular misalignment can cause mild to severe degradations to binocular
vision and acuity and be a grave hazard in aviation.

WAIVER: History of strabismus surgery is considered disqualifying for all aviation duty. A waiver
will not be considered for an SNA applicant, due to the risk of progressive degradation to
alignment even decades later. A waiver for aviation duty other than an SNA applicant will be
considered on a case-by-case basis no sooner than six months after a successful and stable
strabismus surgery if post-operatively, the member otherwise meets the visual standards
appropriate for his or her duty.

INFORMATION REQUIRED:
1. Submission must include an ocular motility worksheet (see chapter 12.14) completed at
the time of waiver request by a provider qualified to measure all required data.
2. Include copies of all eye exams and operative report(s) with AMS.

TREATMENT: Strabismus surgery involves enhancing or retarding the action of one or more
extraocular muscles in either or both eyes. An extraocular muscle tendon may be shortened
(resection) to strengthen its action, or the insertion of the muscle moved posteriorly on the globe
(recession) to weaken its action. Suspending the tendon on hangback sutures is an alternative
to traditional recession surgery. Adjustable sutures may be employed to fine tune ocular
alignment in the perioperative period. A spacer may be inserted in the muscle tendon with
unusual forms of vertical muscle surgery. In general, vertical muscle strabismus surgery is
more complex and problematic than horizontal muscle surgery for simple eso- or exotropia.

DISCUSSION: Ocular misalignment is always the consequence of disease and never a normal
finding. Surgery on extraocular muscles is imprecise and has a risk of regressing to the original
state of misalignment or progressing in effect and causing sequential overcorrection. Multiple
surgeries are frequently necessary for congenital misalignment. Scarring of the globe and
adnexa after muscle surgery may lead to restricted ocular movements. Vertical muscle surgery
often causes or does not fully correct cyclotorsional misalignment.
Realignment of the eyes with muscle surgery does not resolve the underlying disorder in
congenital misalignments and while peripheral binocular function may be partially enhanced,
normal central binocular stereopsis is rarely achieved. Even after satisfactory surgical
alignment in congenital esotropia, residual comorbidities such as latent nystagmus and
dissociated vertical deviations are often seen. The desirable cosmetic result after strabismus
surgery is 10 or fewer prism diopters of misalignment, since this relatively small degree of
heterotropia is not noticeable to casual observation of the eyes. Asymptomatic vision (i.e.
normal acuity without diplopia complaints) with tropia less than 10 prism diopters, meets the
NOHOSH standard for Class II and III.

“NOHOSH” stands for “No obvious heterotropia or symptomatic heterophoria”. “Obvious


heterotropia” is visually noticeable misalignment of the two eyes in primary, straight-ahead gaze
(with no head turn or tilt) or noticeable misalignment during motility testing in the cardinal fields

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of gaze. “Symptomatic heterophoria” is complaints of intermittent diplopia while alert and
performing tasks such as night-driving, night-flying, scanning for air-traffic in hazy skies, etc.

ICD-9 CODES:
H153 Surgery for strabismus or ocular muscle imbalance

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12.6 EXCESSIVE PHORIAS
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Excessive phorias are frequently associated with defective


stereopsis and/or diplopia complaints, a hazard if this occurs during a critical phase of flight.

WAIVER: CD for Class I aviators. No waivers are considered.

INFORMATION REQUIRED:
1. Evaluation by a qualified optometrist or ophthalmologist is necessary.
2. The consult should address any history of diplopia or previous eye surgery, and include
all the studies requested on the accompanying ocular motility worksheet (see chapter
12.14)

ICD-9 CODES:
378.4 Excessive Phorias
378.41 Esophoria
378.42 Exophoria
378.43 Hyperphoria

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 10


12.7 RETINAL DETACHMENT
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: A detached or torn retina can lead to visual impairment, the
degree of which depends on the part of the retina involved and the success of any timely
surgery. Some retinal repairs involve injecting gas into the eye (pneumatic retinopexy), which
will restrict the patient from air transport for some time afterward.
Routine exposure to slow-onset G forces has not been shown to increase the risk of retinal
detachment.
Small atrophic peripheral holes generally do not require treatment, but should be monitored for
progression or subretinal fluid development over time by annual dilated examinations.

WAIVER: Waivers will not be considered in SNA applicants for retinal detachments involving
intraocular repairs, vitrectomy, pneumatic retinopexy or sclera buckles. SNA applicants with
small peripheral tears and/or detachments treated successfully with laserpexy may be
considered on a case-by-case basis after six months with stable follow-up examinations.
Waivers in other designated classes will be considered on a case-by-case basis after a
minimum of three months post-operatively. Annual dilated exams will be required for any
waivered retinal tear, treated holes or detachment. A Grounding physical is required to be
submitted upon diagnosis due to the post-operative observation period of greater than
60 days.

INFORMATION REQUIRED: Please submit all relevant eye examinations and operative reports
to include a Humphrey Visual Field, detailed retinal drawings, motility exam (if scleral buckling is
performed), and glare testing if a pneumatic retinopexy (air injection) or vitrectomy is performed.

TREATMENT: Surgical intervention is required in most cases. The best approach will be
determined by the surgeon and may consist of one or more of the following techniques
cryotherapy, laser retinopexy, pneumatic injection, scleral buckling, or vitrectomy.

DISCUSSION: Visual acuity and visual field loss, changes in refractive error, motility disorders,
and cataracts are frequent sequelae for retinal detachments. Detachments involving the macula
have the highest impact on central vision. Annual follow-up is required for the duration of
military service and recommended after separation from service.

ICD-9 CODES:
361.0 Retinal Detachment with retinal defect

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12.8 GLAUCOMA & OCULAR HYPERTENSION
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Glaucoma is an optic-nerve disease characterized by a


combination of two or more of the following: elevated intraocular pressures, visual field loss
and/or progressive cupping of the optic nerve. It may be associated with increasing age, a
family history of glaucoma, racial predilection, underlying eye conditions associated with
elevated pressures, or trauma to the involved eye.

Open angle glaucoma is the most common type and is usually asymptomatic, even as vision
loss is occurring slowly. Gradual, almost imperceptible loss of peripheral visual field is typically
the earliest clinical manifestation with loss of central vision occurring only in the most advanced
later stages of the disease. Elevated eye pressure is not always present in patients losing vision
from open angle glaucoma. Roughly a third of those presenting with glaucoma have intraocular
pressures (IOPs) less than 22 mmHg and some will continue to lose vision even with a lowering
of their IOP with eyedrops or surgery.

Acute angle glaucoma is much less prevalent and will present in a much different manner then
the open angle variety, with symptoms such as acute onset of eye pain, decreased vision, and
halos around lights. Signs may include a red eye with a hazy cornea and a mid-dilated, poorly
reactive pupil.

Both types require referral to the eye clinic with an acute angle attack requiring emergency
referral to an ophthalmologist to reduce the risk of swift and severe vision loss. Both types of
glaucoma are considered disqualifying because the risk of loss of vision and peripheral visual
fields is incompatible with flight duties.

Ocular hypertension (i.e. elevated pressures in the eye, without visual field loss, or optic nerve
cupping) is not equivalent to the actual diagnosis of “glaucoma”. In fact, most people with what
is often considered to be high pressure (>22 mm Hg) never develop vision loss. This
population, nonetheless, is at higher risk of developing glaucoma and so this condition is also
considered disqualifying.

WAIVER: For the purposes of Naval Aviation, any IOP consistently (on at least 2 different
exams on different days) and accurately measured above 22 mmHg by contact tonometry
(applanation tonometer or tonopen), is considered disqualifying whether or not the diagnosis is
simply ocular hypertension or glaucoma. Simply large optic nerve cupping alone is not
disqualifying, if all other glaucoma screening tests and intraocular pressures are normal.

Any diagnosis of glaucoma is considered disqualifying regardless of IOP. “Glaucoma


Suspicion” is not considered disqualifying, though patients are encouraged to undergo ongoing
screening evaluations by an ophthalmologist or credentialed optometrist every six to eighteen
months.

Designated: Waivers are considered on a case-by-case basis.

Applicants: Waivers will not be considered for actual glaucoma, or ocular hypertension
(corrected for corneal thickness or pachymetry measurements).

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INFORMATION REQUIRED:

Initial Evaluation:
A complete eye exam must include the following:
1. IOP by Goldmann applanation tonometer or Tonopen
2. Central Corneal Thickness (pachymetry)
3. Dilated fundus examination (to include comment on the cup-to-disc ratios and
description of the nerves)
4. Automated visual field testing (30-2 or 24-2 SITA, standard or fast protocols are
acceptable, ensure reliability of the test, and repeat any abnormal field examinations,
submit ALL testing)
5. Slit lamp examination
6. Gonioscopy grading reports on the angles of the eye
7. Retinal nerve fiber layer analysis (i.e. ocular coherence tomography or OCT) is required.

Annual Waiver Evaluation:


A complete eye exam must include all of the above except:
1. Central corneal thickness
2. Gonioscopy, except when clinically indicated by the eye care professional.

TREATMENT:
The following are acceptable topical agents and non-invasive treatments:
1. Prostaglandin analogs are the initial treatment of choice due to insignificant incidence of
systemic side effects.
2. Beta blockers – side effects of reduced exercise tolerance, orthostatic hypotension and
loss of G-tolerance.
3. Carbonic anhydrase inhibitors – side effects of tingling in hands and feet, depression,
anemia and sluggishness.
4. Sympathomimetic eye drops – side effects of hypertension, tremors, tachycardia,
headache, conjunctivitis, anxiety.
5. Laser treatments to the angle of the eye (selective laser trabeculoplasy or SLT) may
reduce the intraocular pressures for up to five years, and may reduce or eliminate the
need for eye drops during this time. Re-treatment may be necessary, and routine follow-
ups must be maintained.

Beta blockers and carbonic anhydrase inhibitors must NOT be used if there are any significant
side effects, including any reduction in circulatory or respiratory function. The treating eye care
professional must be mindful of the unique cardio-respiratory demands of the aviation
environment, and may need input from the flight surgeon to tailor any medications. Patients
must be instructed in proper drop protocols to reduce systemic absorption (e.g. pinching the
lacrimal sac for two minutes to reduce migration to the nasal mucosa. Miotic drugs are
incompatible with night operations due to the inability of the pupil to dilate to admit sufficient
light.

DISCUSSION:
Waivers may be considered if peripheral visual field loss is minimal, and IOP is stabilized either
with an acceptable topical agent as listed above or with laser trabeculoplasty. Incisional
surgery, including filtration or tube shunt surgery is usually not considered compatible with safe
flight operations. Continuation of the waiver requires annual submission, though eye
examinations are usually conducted more frequently as determined by the treating eye doctor.

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ICD-9 CODES:
365 Glaucoma & Ocular Hypertension
365.04 Ocular hypertension
365.10 Open angle glaucoma
365.20 Closed angle glaucoma

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12.9 KERATOCONUS
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Keratoconus is a degeneration of the cornea leading to


progressive thinning and irregular deformation. Visual acuity may eventually be reduced to the
point that vision cannot be corrected to 20/20 with spectacles or contact lenses. Other
symptoms may include diplopia, haze, ghosting of images or reduced ability to discern low
contrast images.

WAIVER: Waivers will not be considered for applicants, but may be considered in designated
personnel if correctable to 20/20 with spectacles.
Local boards of Flight Surgeons are not appropriate for this diagnosis.

INFORMATION REQUIRED FOR INITIAL AND ANNUAL SUBMISSION:


1. Current ophthalmologic/optometric exam to include:
a. Corneal Topography
b. Best corrected visual acuity (BCVA) with contact lenses (if used).
c. BCVA with spectacles

TREATMENT: Contact lenses are often necessary to achieve the best vision. Advanced
disease management may include a full-thickness corneal transplant, which is not waiverable.
Corneal refractive surgery is an absolute contraindication in the presence of any keratoconus.
Contact lens use in any aviator requires specific authorization on the aeromedical clearance
form (up-chit). Please refer to section 12-16, Naval Aviation contact lens policy.

DISCUSSION: It is very difficult to diagnose keratoconus in the early stages unless a corneal
topographic mapping apparatus is used. Aviators with rapidly increasing myopia or astigmatism
may warrant such testing.
Keratoconus is usually bilateral but in rare cases, may affect one eye only. The symptoms
usually start in the teen years. The condition is slowly progressive in 20%-25% of cases, but
stabilization can occur at any time.

ICD-9 CODES:
371.6 Keratoconus

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12.10 OPTIC DISC DRUSEN
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Optic Disc Drusen (ODD) is prevalent in 1% of the population.


Drusen are calcified proteinaceous bodies located within the optic nerve head that may result in
progressive visual field defects, and less commonly transient disturbance of visual acuity, color
vision, and night vision. ODD is often found during routine exam in asymptomatic individuals
and must be considered with any crowding or elevation of the optic nerve.

WAIVER: A history of ODD is considered disqualifying for all aviation duty. Due to the
possibility of progressive visual field loss, a waiver will not be considered for applicants. Waivers
may be considered in already designated personnel providing the member has no other optic
pathology, significant visual field loss, and otherwise meets the visual standards appropriate for
his or her duty.
Local Boards of Flight Surgeons are not appropriate in this situation since waivers are
considered on a case-by-case basis.

INFORMATION REQUIRED:

Initial Evaluation:
1. Ophthalmology consultation is required for initial waiver request to confirm the diagnosis
of ODD and the absence of other conditions (e.g. papilledema).
2. Complete aeromedical history to include pertinent positives and negatives (e.g.
headaches, pulsatile tinnitus, hypertension, diabetes, family history of ODD).
3. Document presence or absence of visual symptoms and their operational impact (e.g.
transient visual obscurations, perceived scotomas or metamorphopsia).
4. Documented exam to include stereoscopic optic disc evaluation, refraction to best visual
acuity, color vision and Amsler grid testing.
5. Optic disc photos should be obtained for baseline documentation and future monitoring.
6. Automated perimetry visual field testing (Humphrey 30-2 is preferred, but 24-2
acceptable).
7. Retinal nerve fiber layer (RNFL) analysis using Optical Coherence Tomography (OCT) is
required for baseline and future monitoring.
8. B-scan ultrasound (preferred) or CT to demonstrate buried drusen.

Annual Waiver Evaluation:


A complete eye exam and history must include all of the above except #8. Ophthalmology
consultation is required only for initial waiver request; optometry follow-up is acceptable with
submission of all required testing and documentation.

TREATMENT:
None. No evidence or definitive studies exist at this time supporting surgical intervention.

DISCUSSION:
Optic Disc Drusen is an indolent and progressive condition, with studies showing as high as
75% of those with ODD developing visual field abnormalities. Central vision may be affected
with rare cases of anterior ischemic optic neuropathy or retinal bleeding from choroidal
membranes. A thorough, detailed history and a comprehensive eye exam are essential to
ensure that the individual has optimal nerve function. While the risk for sudden incapacitation

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 16


from visual obscuration is extremely low, there remains a constant threat to the aviator’s field of
vision with reduced peripheral visual cues for maintaining safety of flight.

Candid reporting of any change in visual performance by the aviator is as important as objective
annual Amsler grid and visual field testing to ensure the safety of flight and mission readiness.

ICD-9 CODES:
377.21 Optic Disc Drusen

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 17


12.11 RETINAL VASCULAR OCCLUSION
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Symptoms vary and range from mild peripheral visual blurring to
severe central vision loss. Onset is usually painless with rapid onset of vision symptoms within
minutes to hours.

WAIVER: Waivers will not be considered in applicants. Designated personnel may be


considered for waiver after vision returns to class standards, and on no further treatments or
frequent follow-ups. Annual submission will be required.

INITIAL WAIVER:
1. All ophthalmology consultation notes from time of first diagnosis and subsequent visits
documenting treatments and visual recovery to normal.
2. Retinal photos of baseline disease and post-treatment retina. Submit copies of any
fluorescein angiography (FA) performed at the time of initial presentation, and any
subsequent FA.
3. Exclusion of other pathology such as hypertension, diabetes, blood dyscrasias, multiple
myeloma and dysgammaglobulinemia is required.

ANNUAL WAIVER:

1. Ophthalmology consultation required, with retinal photos, drawings and all other
documentation showing stability of the disease and vision.

TREATMENT: Photocoagulation and/or intraocular medication injections are sometimes useful


in central retinal vein thrombosis and in long-standing cases of branch retinal vein occlusion.
Hyperbaric oxygen treatment may be considered in retinal artery occlusion, contact the
hyperbaric medicine branch of NAMI for emergent treatment locations and protocols.

DISCUSSION: Macular edema occurs in 57% of cases of occlusion of the temporal branch of
the retinal vein. Visual acuity improves in 60% of patients with branch retinal vein occlusion and
50% achieve visual acuity of 20/40 or better within 1 year. In central retinal vein occlusion,
neovascular glaucoma develops in 15% of cases.

ICD-9 CODES:
362.3 Retinal Vein Occlusion

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 18


12.12 UVEITIS
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Uveitis is the inflammation of any of the intraocular pigmented


uveal tissue, which includes iris, ciliary body and posterior sub-retinal pigmented epithelium.
Anterior intraocular eye inflammation (often referred to as iritis or anterior uveitis) can result in
severe eye pain, photophobia, and blurred vision. Although it is usually an isolated idiopathic
condition, there may be an associated underlying auto-immune disease. Eye pain, photophobia
and chronic steroid use are incompatible with flight, and recurrent episodes are difficult to treat
in the austere environments of shipboard duty or in far-afield outposts without ophthalmologic
care available.

WAIVER: A waiver can be considered for a single episode of iritis that resolves without
complication and is not associated with any underlying systemic condition. A waiver will not be
considered for recurrent uveitis of any type, or for any posterior uveitis, in applicants. Any
associated underlying diagnoses should be considered carefully when determining waiverability
for designated persons.

INFORMATION REQUIRED:
1. Ophthalmology consult is preferred, with dilated fundus examination to exclude posterior
disease. Iritis history to rule out other causative diseases. Recurrent episodes will
require laboratory workup for underlying autoimmune or infectious disease.
2. Appropriate referral as necessary for any underlying systemic condition.

TREATMENT: Treatment for uveitis depends on the portion of the uvea that is affected.
Anterior uveitis is usually successfully treated with topical steroids and cycloplegics to reduce
pain and ciliary body spasm.

DISCUSSION: Uveitis is an inflammation of the uveal layer inside the eye. The uvea consists
of the choroid, ciliary body, and iris. It provides most of the blood supply to the retina. Uveitis
may be unilateral or bilateral and occurs most frequently in people ages 20-50.
Iritis is the most common form of uveitis. These patients have an intense dull pain of the
eye, perilimbal injection and extreme sensitivity to light. The hallmark signs of anterior uveitis
are a constricted pupil on the affected side, and “cells and flare” in the anterior chamber.
WBC’s and proteins are liberated into the anterior chamber as part of the inflammatory
response. In more severe cases, patients may present with keratic precipitates (white blood cell
collections on the posterior corneal surface) and posterior synechiae (iris adhesions to the
anterior lens capsule). Most cases of iritis are idiopathic, but blunt trauma to the eye will
frequently be associated with iritis. Iritis may also be the result of an autoimmune disorder,
infection, or exposure to toxins. A single episode of iritis is generally not an indication for further
testing to determine a systemic cause, however, recurrent, or persistent iritis warrants further
work up.
Posterior uveitis is an inflammation of the choroid and/or ciliary body (inflammation of the
ciliary body, or pars planitis, is often termed intermediate uveitis, however, will be grouped with
posterior uveitis for the purpose of this discussion). Patients with this type of inflammation may
complain of ocular pain and/or floaters, however, are quite often asymptomatic. Comprehensive
slit lamp examination may reveal an inflammatory response (“cells and flare”) in the posterior
chamber. The severity of the response may result in a “snow banking” or “snowball”
appearance, and resultant scarring can form, leading to vision loss.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 19


Possible underlying conditions may include:
Toxoplasmosis Histoplasmosis Tuberculosis
Sarcoidosis Syphilis AIDS
CMV Ulcerative colitis Rheumatoid Arthritis
Herpes Zoster Ankylosing Spondylitis Behcet Syndrome
Reiter Syndrome Lyme Disease

Standard lab tests include:


CBC with differential ANA HLA-B27
RF ACE PPD
FTA-ABS Lyme titer (if appropriate) RPR

ICD-9 CODES:
364.3 Uveitis

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 20


12.13 PTERYGIUM
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: A pterygium is an elevated patch of subconjunctival tissue that


extends from the medial canthus onto the cornea. The slow, progressive encroachment of a
pterygium upon the cornea may lead to progressive astigmatism and refractive error that may
not correct with spectacles. Pterygia may also cause irritation of the cornea and conjunctiva,
resulting in complaints of a red, scratchy, dry eye. The use of UV protective lenses may reduce
the likelihood of pterygium growth and irritation.

WAIVER: Asymptomatic ptyergia up to and including 1.0 mm corneal invasion (measured from
the limbal border at the slit lamp) are NCD for both applicants and designated aviation
personnel, provided vision corrects to 20/20 with spectacles.
Designated aviation personnel with symptomatic pterygia or pterygia greater than 1.0 mm are
CD but a waiver will be considered if vision corrects to 20/20 with spectacles and symptoms, if
present, are controlled with conservative measures such as artificial tears. If a pterygium
requires surgical removal, a waiver may be considered when the member’s vision has stabilized
and is correctable to 20/20, post-op complaints have resolved, and the member is returned to
full duty by the operating surgeon. Aviation applicants with pterygia greater than 1.0 mm are
NPQ with waiver not recommended.

INFORMATION REQUIRED:
1. Ophthalmology or optometry consult to include:
a. Drawing or clear description of the pterygium and the amount of encroachment on
the cornea.
b. Manifest refraction documenting visual acuity corrects to 20/20 with spectacles.
c. Documentation of any symptoms (e.g. tearing, irritation, etc…) and any treatments.
2. Post-op patients also must also submit:
a. Operative report.
b. Clearance for full duty by operating surgeon.
c. Post-op manifest refraction documenting visual acuity corrects to 20/20 with
spectacles.
d. Documentation of absence of post-op complications or complaints.

ICD-9 CODES:
372.4 Pterygium

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 21


12.14 OCULAR MOTILITY WORKSHEET
OCULAR MOTILITY W ORKSHEET
* Exam and the reporting of results MUST conform with the instructions on the back of this form *
Pertinent History

Distant OD 20/ Manifest OD_____________________ Corrected to 20/


Visual Refraction
Acuity OS 20/ OS_____________________ Corrected to 20/

Habitual Rx OD_____________________
Cycloplegic OD___________________ 20/
Refraction
(as needed) OS___________________ 20/ OS_____________________

Prism (if any in specs):_____________


Correction used for remainder of examination  Habitual  Manifest  None
Cover Test

Far: R L Near R L
(all gazes) (all gazes)

Extraocular Motility Maddox Rod or Von Graefe Stereopsis (Verhoeff, Randot, or Titmus)
Prism Diopters Arcseconds

Worth 4 Dot @ 20 feet Vectograph (if available) Red Lens Test

4 Base Out Other test results (as applicable)


(microstrab)

Impression: Is patient NOHOSH?


 Yes  No
Provider Date Provider Phone

Patient Name SSN

Rank/Rate Unit/Address

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 22


INSTRUCTIONS FOR OCULAR MOTILITY WORKSHEET
IF YOU HAVE ANY QUESTIONS PLEASE CALL NAMI OPHTHALMOLOGY AT DSN 922-4558 OR
COMMERCIAL (850) 452-2933, or
Email: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil

PERTINENT HISTORY: Explain why the workup is being done. For example: “scored 7 esophoria on
AFVT” or “muscle surgery OS at age 6 years.”

REFRACTION: SNA applicants need a cyclopentalate 1% cycloplegic refraction recorded, all others
require a manifest refraction only. SNA applicants who see less than 20/20-0 on the Goodlite
Chart unaided also require a manifest refraction recorded.

HABITUAL RX: Record the subject’s habitual Rx here if different from the manifest. If none is used, or
the subject wears contact lenses, please note on the form.

COVER TEST: Report numerical prism diopter values. Do horizontal and/or vertical as applicable to the
case. Horizontal limits are approximately 45 degrees to the left and right of center. Vertical limits
are approximately 25 degrees above and 35 degrees below center. Limits may need to be
modified as dictated by the size of the nose and brow.

EXTRAOCULAR MOTILITY: Give description, such as “Smooth and full.”

MADDOX ROD/VON GRAEFE: Report numerical prism diopter values for both horizontal and vertical
phorias. Fixation target must be at 20 feet.

STEREOPSIS: Verhoeff, done at 1 meter in a normally lit room. Neither the device nor the patient
should move during the test. Randot or Titmus stereo testing acceptable, do not allow head
movement. Report in Arcseconds.

WORTH 4 DOT: Perform at both distance and near. Report “fusion,” “diplopia,” or “suppression OD (or)
OS.”

VECTOGRAPH: (If available) Test on the 20/40 (V O C S R K 4) line of the A.O. Vectographic slide.
Report any suppression, and which eye is suppressing. If there is no suppression, state so. If
not available, put “Not Available”.

RED LENS TEST: (If available – Required for USAF) Test all 9 position of gaze, just like the cover test.
Report any diplopia. If no diplopia is reported, state so.

4 BASE OUT TEST: This test is not always applicable and may be left blank if not used. Prism
introduced over either eye to look for suppression. Can augment the diagnosis of
microstrabismus.

NOHOSH = No Obvious Heterotropia or Symptomatic Heterophoria. Answer this question if the subject
is NPQ (Not Physically Qualified for SNA (Student Naval Aviator), but would consider applying for
the SNFO (Student Naval Fight Officer) program.

PROVIDER PHONE NUMBER: Indicate both DSN (military) and commercial.

Acronyms/definitions:
NAMI: Naval Aeromedical Institute (Pensacola, FL)
AFVT: Armed Forces Vision Tester
SNA: Student Naval Aviator
SNFO: Student Naval Flight Officer
Verhoeff: Specialized manual stereo tester.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 23


12.15 CORNEAL REFRACTIVE SURGERY (PRK/LASIK)
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS:

Definitions:

Corneal Refractive Surgery (CRS): A laser is used to reshape the anterior corneal surface
reducing refractive error and reliance on spectacles or contact lenses. A “wavefront-guided”
(WFG) or “custom” procedure uses wavefront analysis technology, and may improve the visual
outcome of the procedure.

Photorefractive Keratectomy (PRK) or Laser-Assisted Epithelial Keratectomy (LASEK):


Laser energy is applied to the anterior corneal surface after the epithelium is temporarily
displaced or removed. No corneal flap is created. PRK variants include LASEK (epithelium is
preserved), and Epi-LASIK (epithelial flap is created). Pain can be moderate to severe, and
visual recovery can take months.

Laser in-situ keratomileusis (LASIK): A cornea stromal flap is created with a surgical blade or
infrared laser after which, an excimer laser is used to reshape the exposed corneal stroma. The
corneal flap is then repositioned. Pain is minimal and vision recovery is much faster than PRK.

All forms of refractive surgery are disqualifying for aviation duty, but waivers are readily
granted if the member meets all waiver guide policy guidelines. Designated members who
undergo refractive surgery shall be grounded at the time of surgery, but a grounding physical is
not required. Designated members shall not return to flight duty until a Local Board of Flight
Surgeons (to include one eye provider) recommends a waiver via an Aeromedical Summary
(AMS) and issues a ninety-day temporary aeromedical clearance notice.

Both PRK and LASIK are waiverable at this time (see specific sections below).

All other forms of refractive surgery, or any vision or corneal manipulation or surgery,
including RK (radial keratotomy), LTK (laser thermal keratoplasty), ICR (intracorneal ring), ICL
(intraocular corrective lens), and clear lens extraction, are permanently disqualifying
(CD/WNR) for all aviation duty Class I, II and III personnel. The prior use of orthokeratology
(rigid contact lens corneal reshaping) is NCD provided that it is permanently discontinued prior
to obtaining flight status and all appropriate refractive standards are met with stable topography.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 24


PRK AND LASIK GENERAL GUIDELINES (applicants and designated personnel)
1. Post-operatively, the member must still pass all MANMED vision standards for their
class or applicant status, and must wear corrective lenses while flying, if required, to
achieve the vision standard.
2. Refractive stability and a satisfactory postoperative slit lamp exam are required. Trace,
stable, peripheral haze that is not visually significant, is not a hindrance to waiver.
Brightness acuity testing is required for any corneal haze.
3. There must be no symptoms or conditions that would be cause for concern during flight
duties, including, but not limited to: post-operative discomfort requiring ongoing care,
moderate or severe dry eye requiring the use of artificial tear drops more than 4 times
per day or punctal plugs, recurrent corneal erosions, or visually significant glare, haloes
or starbursts.
4. A subsequent PRK or LASIK enhancement or “touch-up” must meet the same timeframe
and clinical guidelines, and requires a second waiver submission package and AMS.
5. Wavefront-guided LASIK (“Custom LASIK”) is preferred in aviation personnel, as custom
treatment may increase visual acuity and final vision outcomes, but in no way is required
for a waiver recommendation, as not all patients are candidates for custom treatments.
LASIK may reduce the risk of significant haze symptoms, which can occur after PRK.
LASIK also reduces the operational down-time before a waiver application may be
submitted for designated aviation personnel. The final decision of performing PRK or
LASIK is made by the operating ophthalmologist with the patient’s informed consent.
6. Copies of pre-operative, and post-operative examination paperwork, including the laser
treatment reports, are required for waiver considerations. NAMI may request additional
information as deemed medically necessary to make a waiver determination.
7. For PRK and LASIK waiver renewal, submission is as stated in the member’s BUMED
waiver letter. All new refractive surgery waiver approvals will usually only require routine
five-year submission.

Applicants only:
1. Applicants may not have more than 3D of pre-operative cylinder and 3.5D of pre-op
anisometropia, and must satisfy the above general guidelines, as well as the following
guidelines:
a. SNA applicants shall not exceed pre-operative refractive limits of +3.00 to -8.00
(SE) for either PRK or LASIK, and must additionally have a post-operative
cycloplegic refraction using cyclopentolate performed at a military installation.
b. Class II & III applicants: pre-operative refractive error shall not exceed +6.00 to
-8.00 (SE) for PRK or LASIK.
c. Civilian applicants must obtain PRK or LASIK at their own expense at a civilian
refractive surgery center. DoD instruction 6130.03, enclosure 4, requires a six month
minimum wait time before submitting LASIK or PRK waiver requests for civilian
accessions. All paperwork and operative reports must be available and submitted for
waiver consideration.
d. Active duty applicants with a normal and stable post-operative course who are
applying for aviation programs (i.e. STA-21, UAV operator, NFO/SNFO to SNA
transition, etc.), may be considered for waivers at 3 months, with due consideration
for all MANMED and ARWG policies and guidelines.
e. Active duty applicants may have astigmatism correction up to 6D of cylinder, per
FDA limits on the respective laser platform utilized. Programs leading to a
commission must still adhere to the 3D cylinder limit.
f. Active duty aviation students (SNA, SNFO, etc.) who are authorized to undergo
refractive surgery by the aviation training command may be considered for waivers at

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 25


3 months. Active duty members require treatment at a military refractive surgery
center. Aviation students may have astigmatism correction up to 6D of cylinder, per
FDA limits on the respective laser platform utilized.

Active duty aviation personnel only:


Designated aviation personnel must satisfy all the above general guidelines and the
following guidelines:

1. A PRK waiver request may be submitted after the following wait periods:
a. myopia -6.00 diopters or less spherical equivalent (SE): 3 months
b. myopia greater than -6.00 diopters SE: 6 months
c. hyperopia SE: 6 months
2. A LASIK waiver request may be submitted after the following wait periods:
a. myopia correction up to -11.5D SE: 2 weeks
b. hyperopia up to +4D SE: 4 weeks
c. hyperopia greater than +4D SE and up to +6D SE: 8 weeks
3. If still requiring prescription topical medication (artificial tears, or cyclosporine drops
excluded) then restriction of flight activities to the local area is recommended.
4. Class I aviators, specifically, must undergo PRK or LASIK treatment at one of the USN
designated refractive surgery centers which have Navy ophthalmology staffing (includes
Tripler AMC, Keesler AFB, or Wilford Hall). Check for a current listing if considering a
non-Navy facility since staffing may change.
5. Class II, III, and other active duty flight personnel (e.g. UAV personnel, select
passengers) may undergo PRK or LASIK at any DoD refractive surgery center.
6. For PRK, pre-operative refractive limits are per the FDA limits for the particular refractive
laser platform utilized, for already designated personnel within their aviation class. For
LASIK, waivers may be granted for myopia up to -11.5D spherical equivalent (SE),
hyperopia up to +6.00D (SE), and up to 6D of cylinder (astigmatism correction).
7. For both PRK and LASIK, the PRK AMS template (available on the NAMI waiver guide
website) may serve as a Local Board of Flight Surgeons, requiring review and
endorsement by two flight surgeons, plus an eye care provider (military optometrist or
military ophthalmologist), and commanding officer cognizance. A ninety-day
aeromedical clearance notice may be issued at that time, pending BUPERS waiver
approval. Submit the AMS and waiver package immediately to NAMI to avoid
unnecessary delays in obtaining BUPERS final approval.
8. No deployment for at least three months following PRK and one month following LASIK
surgery (per NAVMED POLICY 08-008, dtd 10 JUN 2008). Post-operative operational
training requirements (such as CS gas, pepper spray, water survival training, etc.) may
be performed per ophthalmologist guidance.

Select Reserve designated aviators:


Reservists must satisfy all the above general guidelines and the following guidelines:
1. May obtain PRK or LASIK at their expense from civilian sources of care.
2. A pre-operative evaluation is strongly encouraged to be submitted to NAMI
Ophthalmology before corneal refractive surgery is performed. Contact NAMI
Ophthalmology at 850-452-2933 or
usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil.
3. Final approval to proceed with PRK or LASIK requires written permission from the unit
commander and unit flight surgeon.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 26


REFRACTIVE SURGERY DISCUSSION:
The goal of corneal refractive surgery is to reduce or eliminate dependence on spectacles or
contact lenses, which can be bothersome at times while flying. Refractive surgery has been
studied extensively in the aviation environment and has yielded highly satisfying results. More
than 95% of Naval Aviators reported “increased effectiveness” after undergoing refractive
surgery.

Wavefront guided (WFG), or “custom” refractive surgery has been evaluated by the Naval
Refractive Surgery Center and yielded results that are superior compared to conventional
treatment. Based on this analysis, aviation personnel should undergo a wavefront-guided or
custom procedure, if at all possible. Some patients are not candidates for a wavefront-guided
treatment or LASIK for various reasons, and conventional or PRK treatment remain viable
options.

As with any surgical procedure, there are inherent risks, such as quality of vision deficits (e.g.
halos and glare at night), haze, flap complications and persistent eye discomfort (e.g. dry eye or
recurrent erosions). A detailed description of the risks, benefits, and alternatives should be
discussed and consented between the patient and their refractive surgeon.

Undergoing PRK or LASIK does not guarantee qualification for aviation. The member must
meet pre-operative standards in MANMED and this waiver policy guide. Post-operatively the
applicant must meet all MANMED vision standards appropriate to their aviation class.

When obtaining corneal refractive surgery it is incumbent upon the member and the member’s
commanding officer and flight surgeon to be aware of corneal refractive surgery waiver
recommendations at the time of the surgery and subsequent submission. Rapidly evolving
technology results in changes to waiver guidelines when appropriate. Every effort will be made
to publish new regulations widely, but the only valid source of current recommendations shall
remain the Manual of the Medical Department. When in doubt, NAMI ophthalmology remains
available for consultation through phone or email: 850-452-2933;
usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil

ICD-9 CODES:
P1177/H1177 PRK
P1171/H1171 LASIK

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 27


The following table outlines recommended wait times for activities after refractive surgery.
Please contact your local Eye Provider or the NAMI Eye Department for more information.

***NOTE: ICLs are NOT approved for any class of Naval Aviation, including Unmanned Aerial
System Operators.

LASIK: Laser-Assisted In-Situ Keratomileusis


PRK: PhotoRefractive Keratectomy
ICL: Intraocular Corrective Lens (*** not approved for flight duties)
ICL*** LASIK PRK
No restriction.
Showering or washing face.
Note: You should always avoid getting water in the eyes, and
pat the eyes dry (do not rub the eyelids)
5-7 days (after
Air travel as a passenger 3 days removal of bandage
contact lens)
Aerobic activity (walk, run, bike, As soon as pain As soon as pain and
exercise machines) or weight and light sensitivity light sensitivity have
2 weeks
training. Notes: Avoid getting have resolved: resolved:
sweat, dust, or wind in eyes. 1-2 days. 3-5 days.
Bending over (toe touches, sit-ups ) 2 weeks No restrictions.
1 month.
1 month. Optional eye
Note: There is a lifelong risk of opening
Contact sports: Martial arts, protection should
surgical wounds with trauma to the eye.
basketball, boxing, wrestling always be considered
If you resume these activities, you must
in contact sports.
wear eye protection.
Exposure to hot tubs, pools, lakes, 1 month
ocean, river Note: Risk of infection from contaminated water
2 weeks
Wearing eye make-up, including Note: Infection risk from contaminated make-up. When make-
camouflage face paint up use is resumed, start with new, freshly opened products. Old
eye makeup should be discarded.
Working in a dusty or dirty
environment: outdoor rifle range, 1 month 2 weeks 1 month
deploying to the field, gardening
CS exposure (gas chamber) or OC
3 months 6 months
spray (pepper spray) exposure
Driving an automobile or
When patient meets the visual acuity requirements, and feels
motorcycle with goggles or face
comfortable.
shield
Full time first month,
as much as possible
nd th
Wearing UV protection (sunglasses) Wear UV protection whenever practical. the 2 -4 months,
and whenever
practical afterwards.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 28


12.15A LASIK IN DESIGNATED AVIATORS STUDY
Last Revised: APR 15 Last Reviewed: APR 15

Class I, Class II: The LASIK Study for designated Class I and Class II personnel has been
closed. Be aware that Class I personnel are required to have their LASIK procedure performed
at one of the DoN Refractive Surgery Centers (including Tripler AMC and Keesler AFB, which
have Navy ophthalmology support). Class II personnel may have LASIK performed at any DoD
refractive surgery center, being mindful of current refractive policy limits for waivers. For
designated personnel previously enrolled in the study, annual submission is required for
renewal with supporting documentation per the LASIK study protocol.

12.15B LASIK IN STUDENT AVIATORS STUDY


Last Revised: APR 15 Last Reviewed: APR 15

WAIVER: The LASIK Study for Student Naval Aviators Study has been closed to new enrollees;
but, LASIK is still waiverable for new candidates and students in all aviation classes. Contact
Information: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil, Contact Phone: 850-
452-2933.

Discussion: “All-laser” LASIK is preferred, which utilizes two types of lasers: one to create the
LASIK flap and another to perform the corneal vision correction. The laser flap is preferred over
a metal keratome blade to reduce the risk of operative complications and enhance post-op
stability. “Wavefront-guided” or custom LASIK is preferable, if available, and the patient is a
candidate for such after evaluation by their surgeon. “All-laser, custom LASIK” gives a better
visual outcome over conventional treatments. This has been borne out by repeated Navy
research studies. Please note that no specific method of LASIK is mandatory for waiver
consideration, as long as all pre- and post-op criterion and vision standards are met in Chapter
12.15 of this waiver guide.

ICD-9 CODES:
P1171/H1171 LASIK

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 29


12.16 NAVAL AVIATION CONTACT LENS POLICY
Last Revised: MAR 15 Last Reviewed: Apr 2015

All classes of Naval aviation personnel shall be allowed to wear contact lenses during duty
involving flight when the following requirements have been met as outlined below, and allowed
by local commander’s policy in theater. A notation from the flight surgeon authorizing contact
lens use is required on the aeromedical clearance notice (up-chit) DD2992. Contact lens use is
not considered disqualifying (NCD). A waiver for their use is not required.

REQUIREMENTS:
1. Visual requirements specific to each class and service group must continue to be met
while wearing contact lenses.
2. Near visual acuity must be 20/20 in each eye. Presbyopic personnel may use spectacles
over their contacts to achieve this standard.
3. There must be no symptoms incompatible with safe flight, e.g. fluctuating vision,
reduction in vision at night or under glare conditions, or discomfort.
4. Must have worn contact lenses on a daily basis without complication for a minimum of
one month before their use can be authorized on the “up-chit”.
5. The prescribing eye doctor must note in the patient’s record that a good fit has been
achieved and that no further changes are planned.
6. SCLs are not to be worn overnight while in flight training or flight status unless
operationally mandated. If extended contact lens wear (greater than 24 hours) is an
operational requirement, lenses may be worn for a maximum of seven consecutive days.
Personnel are encouraged to limit extended wear to the shortest period possible. A
minimum 12 hour recovery period, during which no contact lenses are worn, shall follow
each extended wear period. Rigid gas permeable lenses shall not be used overnight.
7. During aviation duties, it is the responsibility of all contact lens wearers to carry clear
spectacles in a readily accessible protective case which correct the wearer's vision to all
applicable standards.
8. Follow-up examinations for personnel wearing contact lenses shall be conducted at least
annually by a Navy optometrist or ophthalmologist.

APPROVED CONTACT LENSES:


1. Only nationally available, FDA approved lenses and solutions are allowed.
2. Lenses of first choice shall be FDA approved silicone hydrogel contact lenses. Rigid gas
permeable lenses are permissible, but strongly discouraged.
3. The following are NOT authorized:
a. Bifocal/multifocal contact lenses.
b. Cosmetically tinted contact lenses.
c. Sports tinted contact lenses (e.g. amber or green).
d. Contact lens wear for corneal refractive therapy (ortho-K).
4. The following are only authorized with an appropriate waiver:
a. Combinations of rigid and soft contact lenses.
b. Contact lens use for therapeutic reasons such as keratoconus or basement
membrane dystrophies.

For any other questions regarding specific brands of contact lenses or waiver issues, please
contact:
Phone: NAMI Eye Department at 850-452-2933
Email: usn.pensacola.navmedotcnamefl.list.nami-ophthal@mail.mil

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 30


12.17 ALLERGIC CONJUNCTIVITIS
Last Revised: APR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: The condition can cause blurred vision, ocular itching, burning,
tearing/discharge, eyelid edema, and photophobia. These signs and symptoms, along with the
use of medications with unacceptable side effects, have the potential for in-flight incapacitation
and prolonged periods of grounding.

WAIVER: Chronic and perennial allergic conjunctivitis is CD for all applicants according to the
MANMED. Seasonal allergic conjunctivitis in designated personnel is NCD. The member shall
be grounded while symptomatic. A waiver is not required if the member is treated with an
approved medication. If the condition is associated with rhinitis, see chapter 6.1,
ALLERGIC/VASOMOTOR RHINITIS.

TREATMENT: Mild symptoms of allergic conjunctivitis may be relieved by cool compresses


and artificial tears to flush away the allergens. Moderate to severe symptoms may require, in
addition to cool compresses and artificial tears, ophthalmic antihistamines and/or mast cell
stabilizers. Only prescription ophthalmic antihistamines and mast cell stabilizers are
approved for waivers.

OTC or prescription ophthalmic vasoconstrictors, decongestants, NSAIDS, and corticosteroids


are not approved. Note that ophthalmic antihistamines containing vasoconstrictors and/or
decongestants are not approved. If necessary for severe seasonal allergic conjunctivitis, non-
sedating oral antihistamines may also be used, see 6.1 ALLERGIC/VASOMOTOR RHINITIS for
an approved list of medications.

DISCUSSION: Two forms of allergic conjunctivitis are quite common: seasonal (SAC) and
perennial (PAC). SAC coincides with pollen blooms (e.g., ragweed, trees, grasses).
PAC may occur at any time or even year round (e.g., exposure to ubiquitous cat dander,
chemicals or dust). The most effective treatment is elimination or avoidance of the potentially
offending allergen, although this may not always be possible or practical.
Due to the potential chronicity of allergic conjunctivitis, long term use of medication may be
necessary to keep the member asymptomatic for aviation duties, including nasal and inner ear
functionality. The flight surgeon should be cognizant that the aviator or aircrew member may
have residual allergy symptoms such as itchy, tearful eyes, runny nose, sneezing, scratchy
throat and other allergic symptoms which would preclude flight until effectively treated.
Ophthalmic antihistamines and/or mast cell stabilizers have minimal side effects and are
approved for use in aviation personnel. Contact lenses may exacerbate the condition and
should not be worn until the member is asymptomatic.

ICD-9 CODES:
372.14 Chronic Allergic Conjunctivitis
372.05 Acute Atopic Conjunctivitis

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 31


12.18 CENTRAL SEROUS RETINOPATHY
Last Revised: MAR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Central serous retinopathy (CSR) is a unilateral, localized


detachment of the retina in the macular region which may cause decreased or dim vision,
distortion or miniature appearance of objects, and/or washed out color vision.

WAIVER: CSR is considered disqualifying (CD). Waivers will not be considered for applicants
(CD/WNR), but may be considered for designated personnel. Evaluation by an optometrist or
ophthalmologist is required with an annual submission.
Local boards are authorized for initial cases of CSR once condition has resolved (cleared
by optometry/ ophthalmology), if less than 60 days has elapse since diagnosis, best
corrected visual acuity has returned to the aviator’s specific class standard, the aviator
is asymptomatic to visual disturbances, and no metamorphopsias are noted on Amsler
Grid testing. Recurrent cases of CSR require a new waiver to be submitted for review and
approved by NAMI for each new episode (no local boards authorized). A grounding physical
is required if more than 60 days has elapsed since diagnosis without resolution.

INFORMATION REQUIRED:
1. Slit lamp examination of the macula with 78/90 diopter fundus lens
2. Amsler grid, documenting any metamorphopsia
3. Optical coherence tomography reports (submit color scans: from diagnosis to resolution)
4. Humphrey Visual Field 10-2 (only required if laser treatment was performed)
5. Fluorescein angiography (optional, at the discretion of the treating ophthalmologist,
submit if performed and photos available)

TREATMENT: CSR is self-limiting with a good prognosis. Eye exams should be performed
every 4-6 weeks until the condition has resolved and vision has stabilized and returned to
baseline. Ocular coherence tomography should be performed upon diagnosis and after
subjective/objective findings have resolved. In certain cases, laser photocoagulation may be
considered to enhance recovery, but may leave a small permanent blind spot.

DISCUSSION: Central serous retinopathy can be visually debilitating to a patient’s central vision
and results in normal to decreased visual acuity ranging from 20/25 to 20/200. This condition
usually occurs in males (10:1), 20 to 50 years old, and is associated with type-A personalities
and increased stress levels. Typically patients recover visual acuity, but a small percentage of
patients may not return to 20/20. Resolution usually occurs over a course of 4-6 months, with
continuing improvement in visual acuity over 24 months. Prognosis is worse for patients with
recurrent or prolonged disease. Laser photocoagulation may be considered for occupational
reasons, if CSR occurs in the contralateral eye, or if no resolution has occurred in more than 6
months. Laser intervention may shorten duration by up to 2 months, but typically has no effect
on the final visual acuity outcome.

ICD-9 CODES:
362.41 Central Serous Retinopathy

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 32


12.19 PIGMENT DISPERSION SYNDROME
Last Revised: MAR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Pigment Dispersion Syndrome (PDS) is a bilateral condition


characterized by the liberation of pigment granules from the posterior iris which deposit on the
anterior cornea, iris, and trabecular meshwork. PDS has the potential to increase intraocular
pressure, leading to secondary glaucomatous damage to the optic nerve and reducing
peripheral vision. The classic “triad” of PDS consists of pigment on the corneal endothelium
(Krukenberg Spindle), trabecular meshwork pigmentation, and transillumination defects (TID) of
the iris.

WAIVER: Any clinical finding of a Krukenberg spindle, trabecular meshwork pigmentation, or


iris transillumination defects warrants a diagnosis of PDS, which is considered disqualifying
(CD) for all aviation personnel.

Waivers are considered for designated personnel if intraocular pressure (IOP) is 22 mmHg or
less in each eye, taking into account corneal thickness (corrected IOP), with no more than 4
mmHg difference between the eyes, normal Humphrey 24-2 visual fields, no glaucomatous
changes present in the optic disc, and no treatment (pressure lowering drops/laser) is indicated.
Local boards are authorized for designated personnel with normal corrected IOP, as long
as no treatment is indicated, and no signs of glaucoma are present on ophthalmologic
examination (normal visual fields, normal optic nerve appearance).

Applicants presenting with a Krukenberg spindle or trabecular meshwork pigmentation, but


without transillumination defects, will be considered for a waiver if the corrected IOP is 22
mmHg or below in each eye and no laser or medical treatment is indicated. Applicants with
transillumination defects or a corrected IOP above 22 mmHg in either eye will not be considered
for a waiver (CD/WNR) due to the high rate of conversion to pigment dispersion glaucoma in
future years.

Waiver submission is required on a routine basis. If the corrected IOP is above 22 mmHg, then
annual submission with a complete glaucoma screening is required. If corrected IOP
measurements are above 22 mmHg by applanation tonometry on two separate occasions, or if
laser/medical treatment is required for management of PDS, then the diagnosis should be
converted to pigmentary dispersion glaucoma (PDG - see Glaucoma chapter 12.8).

INFORMATION REQUIRED:
Initial Waiver:
1. Eye exam by a Navy optometrist or ophthalmologist
2. IOP measurement by applanation tonometry (Goldmann)
3. Central corneal thickness measurement (Pachymetry) with IOP correction factor
4. Automated visual field (24-2 SITA)
5. Optic nerve evaluation with comment on health of neural rims, with color disc photos
uploaded into AERO
6. Slit lamp examination with comment on anterior segment findings related to PDS
7. Gonioscopy to document trabecular meshwork pigmentation

Waiver Continuance:
1. Eye exam by a Navy optometrist or ophthalmologist.
2. IOP measurement with applanation tonometry (Goldmann)

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 33


3. Automated visual field (24-2 SITA)
4. Optic nerve evaluation with comment on health of neural rims, with color disc photos
uploaded into AERO
5. Slit lamp examination with comment on anterior segment findings related to PDS
6. Gonioscopy, if performed

TREATMENT: Besides annual monitoring of PDS, treatment is usually not initiated if IOP is 22
mmHg or less, and there are no signs of glaucomatous changes. However, any glaucomatous
changes or elevation of IOP may cause the eye provider to recommend pressure-lowering
medications or laser treatments (See Glaucoma chapter, 12.8 for discussion on waivers for
glaucoma).

DISCUSSION: Pigment dispersion syndrome (PDS) is a bilateral condition that typically occurs
in young adult males (2:1) under the age of 45. PDS is characterized by liberation of pigment
granules from the posterior iris, depositing in the anterior chamber structures. It can appear
asymmetric between the eyes.

Deposition of this pigment occurs on the posterior corneal surface (‘Krukenberg spindle’ on the
endothelium) and in the anterior chamber angle trabecular meshwork (TM). Pigment in the TM
is deposited in a homogenous pattern, unlike other entities that can cause TM pigmentation
(uveitis, exfoliation syndrome, melanoma, IOL-iris chaffing). Fine pigment granules can also
been seen on the anterior iris surface and the anterior lens capsule. Pigment liberation occurs
as a result of the posterior pigment epithelium of the iris rubbing against the crystalline lens
zonules. Slit-like transillumination defects (TID) will be seen in a radial pattern in the mid-
periphery of the iris when a bright light is shown through the pupil, best seen in a very dark room
in the slit lamp. Pigment liberation can also occur due to ocular trauma or surgery, but TI
defects will rarely be seen. The typical patient with PDS is a young, white male who is myopic
with a slightly concave iris posture. It is uncommon in persons with African or Asian ancestry,
but occurs in up to 2% of the Caucasian population. It appears to have incomplete penetration
by way of autosomal dominant inheritance.

PDS can lead to pigment dispersion glaucoma (PDG), which is a type of secondary open-angle
glaucoma. Conversion of PDS to PDG occurs in approximately 20% of PDS patients within 10
years of initial diagnosis. PDG is diagnosed when the classical triad of PDS is present
(Krukenberg spindle, iris trans-illumination defects, and trabecular meshwork
hyperpigmentation), along with progressive optic nerve cupping, glaucomatous visual field
changes, or ocular hypertension. Treatment should be begun if the IOP is elevated, even
without optic nerve degeneration or visual field abnormalities, to reduce the risk of future optic
nerve damage and vision loss.

ICD-9 CODES:
364.53 Pigment Dispersion Syndrome / Pigmentary Iris Degeneration / Translucency of
Iris

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 34


12.20 PERIPHERAL RETINAL DEGENERATION AND RETINAL HOLE
Last Revised: MAR 15 Last Reviewed: APR 15

AEROMEDICAL CONCERNS: Peripheral retinal degeneration and retinal holes are significant
risk factors for retinal detachment, which can cause a painless, sudden loss of vision that may
permanently impact peripheral and central vision. Retinal degenerations are commonly seen in
highly myopic individuals and the increased risk of retinal detachment remains elevated even
after corneal refractive surgery is performed.

WAIVER: Any peripheral retinal degeneration or retinal hole is considered disqualifying (CD).
A diagnosis of “white without pressure” is a descriptive term for the appearance of the retina and
is Not Considered Disqualifying (NCD). Guidance for designated aviation personnel and
applicants are as follows:

- Peripheral Retinal Degeneration (Lattice degeneration, paving stone degeneration,


snail track degeneration) – Annual waiver with Dilated Fundus Exam (DFE). Local
boards are authorized after DFE is preformed to assess stability and rule out retinal
detachment. Applicants may be considered for waivers through the NAMI waiver
process.

- Peripheral Retinal Hole – Ophthalmology consult is required prior to waiver


consideration. If the hole is considered stable with no sub-retinal fluid and treatment is
not indicated, retinal holes may be considered for an annual waiver with DFE (performed
by optometry or ophthalmology). Holes treated with laserpexy may be considered for an
annual waiver with DFE after one month follow-up time has elapsed and the surgeon
has determined stability. Local boards are authorized after ophthalmology
determines fitness for full duty if less than 60 days has elapse since diagnosis
and treatment. Applicants may be considered for waivers through the NAMI waiver
process.

- Retinal Tear/Detachment – CD, no local boards authorized. See Retinal Detachment


Chapter (12.7) for more information and waiver guidance for applicants and designated
aviation personnel.

INFORMATION REQUIRED:
1. Eye exam with DFE by Eye Care provider (Ophthalmology consult required for retinal
holes) with comment on long-term prognosis
2. Detailed retinal drawings or photographs

TREATMENT: Patient education and monitoring with a comprehensive eye exam, including
dilated fundus examination, is the most common course of action for patients with peripheral
retinal degenerations and retinal holes. Patients with retinal holes should be further evaluated
with scleral depression to ensure the stability of the hole and determine presence or absence of
shallow retinal detachment. Most small, stable holes are monitored annually, but may require
prophylactic laser treatment to reduce the risk of future detachment. Patients should be aware
of the signs and symptoms of retinal detachment, including an increase of flashing lights,
floaters, or blurry or obscured areas of vision beginning in the periphery. The patient should be
educated to return to the clinic for a repeat dilation immediately if they experience these
symptoms.

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 35


DISCUSSION: Peripheral retinal degenerations (specifically lattice and snail-track
degenerations) are vitreoretinal changes in the retina and overlying vitreous usually located in
the far periphery. The involved retina thins and becomes fibrotic, resulting in vitreous pockets
(lacuna) forming above the affected areas of the retina. Lattice degeneration is clinically
prevalent in 10% of patients and is usually non-pigmented, but may become hyperpigmented in
30% of cases. Half the cases of lattice are bilateral, symmetrical, and refractive error does not
play an important factor in the development (seen in 15% of high myopic patients). Snail track
lesions occur in up to 80% of eyes with lattice degeneration and can be associated with myopia.
Although 30% of retinal detachment patients have a predisposed peripheral retinal
degeneration, the clinical rate of detachment is only 0.5%. There is no evidence that
prophylactic therapy reduces the risk of future retinal detachment.

Thinning of the retina may lead to the formation of atropic holes or retinal breaks in 25% of
patients, but the frequency of retinal detachment as a result of retinal holes is low (3-14%).
Most atrophic holes do not require any treatment since they are not associated with vitreous
traction. However, upon discovery of atrophic holes, a consultation to an ophthalmologist is
indicated especially with patients who have high myopia, those who are active in contact sports,
or if there is a family or personal history of retinal detachment.

Retinal ‘white without pressure’ (WWOP) is an optical phenomenon in which vitreous traction
changes the retinal coloration upon examination. WWOP is usually bilateral and observed in
5% of patients over 20 years of age, but roughly 66% in patients over 70 ( 30% of the total
population). White without pressure is an incidental finding and there is no associated risk of
retinal holes, tears, or breaks with this condition.

ICD-9 CODES:
361.31 Round hole of the retina without detachment
362.60 Peripheral retinal degeneration, unspecified
362.61 Paving Stone Degeneration
362.63 Lattice Degeneration

U.S. Navy Aeromedical Reference and Waiver Guide Ophthalmology - 36

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